Failure to Provide Timely ADL and Incontinence Care
Penalty
Summary
Staff failed to provide timely care and assistance with activities of daily living (ADLs) for a resident who was dependent on staff for most ADLs due to multiple medical conditions, including cerebral infarction, muscle weakness, congestive heart failure, contractures, moderate dementia with agitation, and hemiplegia. The resident was assessed as always incontinent of bowel and bladder, required two-person assistance for toileting, dressing, bathing, and hygiene, and was to be checked and changed every two hours and as needed per the care plan and facility policy. On the day of observation, the resident was placed in a chair in the dining room at 7:00 A.M. and was not checked or changed for incontinence until after lunch, despite being visibly soiled and wet for several hours. Multiple observations confirmed the resident remained in the same soiled clothing throughout the morning and early afternoon, with dried food and liquid on her shirt and wet pants. Staff interviews confirmed it was routine not to change the resident until after lunch, contrary to the care plan and facility policy. Upon being changed, the resident's brief was heavily saturated with urine, there was a foul odor, and the resident's skin showed redness and indentations from the soiled brief.